Clinical Reviewer

• Process medical necessity reviews for authorization appropriateness of behavioral health care services
• Assist with discharge planning activities, including outpatient services and home health services
• Coordinate care for members
• Complete prospective, concurrent, and retrospective reviews of Behavioral Health services
• Identify, document, communicate, and coordinate care with collaborative care partners to facilitate transition to an appropriate level of care
• Engage with the medical director when additional clinical expertise is needed
• Maintain knowledge of state and federal regulations, State Contracts, Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Provide guidance to non-clinical staff and support to LPN staff
• Attend medical advisement and State Hearing meetings as requested
• Assist the Team Leader with special projects or research as requested
• Perform other job-related duties as requested

Clinical Care Reviewer II – Behavioral Health, Prefer MA Licensed

• Process medical necessity reviews for appropriateness of authorization for health care services
• Assist with discharge planning activities, including DME and home health services
• Coordinate care for members and monitor delivery of healthcare services
• Complete prospective, concurrent, and retrospective reviews for acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services, and durable medical equipment
• Identify, document, communicate, and coordinate care to facilitate transitions to an appropriate level of care
• Engage with the medical director when additional clinical expertise is needed
• Maintain knowledge of state and federal regulations, State Contracts, Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Provide guidance to non-clinical staff and support LPN clinical staff
• Attend medical advisement and State Hearing meetings as requested
• Assist the Team Leader with special projects or research as requested
• Perform other job-related duties as requested

Clinical Reviewer jobs in United States

Clinical Care Reviewer II – Behavioral Health, Prefer MA Licensed

Clinical Care Reviewer II – Inpatient MCD, Multi State LOB